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2009 Medicare Part D Plan Formulary Information
UPMC for Life Prescription Drug Plan (S3389-005-0) Benefit Details
The UPMC for Life Prescription Drug Plan (S3389-005-0) Formulary Drugs Starting with the Letter G in CMS PDP Region 6 which includes: PA WV
Drugs Starting with Letter G Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter G Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GABAPENTIN 100MG CAPSULE	1	Generic	$5.00	$12.50	None
GABAPENTIN 100MG TABLET	1	Generic	$5.00	$12.50	None
GABAPENTIN 400MG CAPSULE (10 CT)	1	Generic	$5.00	$12.50	None
GABAPENTIN 400MG TABLET	1	Generic	$5.00	$12.50	None
GABAPENTIN 600MG TABLET	1	Generic	$5.00	$12.50	None
GABAPENTIN CAPSULES 300MG (500 CT)	1	Generic	$5.00	$12.50	None
GABAPENTIN TABLET 800MG	1	Generic	$5.00	$12.50	None
GABITRIL 12MG FILMTAB	2	Preferred Brand	$32.00	$80.00	None
GABITRIL 16MG FILMTAB	2	Preferred Brand	$32.00	$80.00	None
GABITRIL 2MG FILMTAB	2	Preferred Brand	$32.00	$80.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GABITRIL 4MG FILMTAB	2	Preferred Brand	$32.00	$80.00	None
GALANTAMINE HBR 12MG TABLET	1	Generic	$5.00	$12.50	None
GALANTAMINE HBR 4MG TABLET	1	Generic	$5.00	$12.50	None
GALANTAMINE HBR 8MG TABLET	1	Generic	$5.00	$12.50	None
GAMASTAN S/D INJECTION 16.5GM/2ML VIALGL	4	Specialty	33%	N/A	P
GAMMAGARD LIQUID 10% VIAL	4	Specialty	33%	N/A	P
GAMMAGARD LIQUID 10% VIAL	4	Specialty	33%	N/A	P
GAMMAGARD LIQUID 10% VIAL	4	Specialty	33%	N/A	P
GAMMAGARD LIQUID 10% VIAL	4	Specialty	33%	N/A	P
GAMMAGARD LIQUID 10% VIAL	4	Specialty	33%	N/A	P
GAMUNEX FOR SOLUTION 10GM/25ML VIALGL	4	Specialty	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GANCICLOVIR 250MG CAPSULE	4	Specialty	33%	N/A	None
GANCICLOVIR 500MG CAPSULE	4	Specialty	33%	N/A	None
GANTRISIN PED 500MG/5ML SUSPENSION	2	Preferred Brand	$32.00	$80.00	None
GARDASIL VIAL	2	Preferred Brand	$32.00	$80.00	P Q:3 /365Days
GASTROCROM 100MG/5ML CONC	2	Preferred Brand	$32.00	$80.00	None
GEMFIBROZIL TABLET 600MG (500 CT)	1	Generic	$5.00	$12.50	None
GEMZAR 1GRAM VIAL	3	Non-Preferred Brand	$80.00	$200.00	None
GEMZAR 200MG VIAL	3	Non-Preferred Brand	$80.00	$200.00	None
GENERLAC SOLUTION 10G/15 ML 473 ML BOTPL	1	Generic	$5.00	$12.50	None
GENGRAF 100MG CAPSULE U.D.	1	Generic	$5.00	$12.50	P
GENGRAF 100MG/ML SOLUTION	1	Generic	$5.00	$12.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GENGRAF 25MG CAPSULE U.D.	1	Generic	$5.00	$12.50	P
GENOTROPIN 5.8MG CARTRIDGE	4	Specialty	33%	N/A	P
GENOTROPIN MINIQUICK 0.2MG	2	Preferred Brand	$32.00	$80.00	P
GENOTROPIN MINIQUICK 0.4MG	2	Preferred Brand	$32.00	$80.00	P
GENOTROPIN MINIQUICK 0.6MG	4	Specialty	33%	N/A	P
GENOTROPIN MINIQUICK 0.8MG	4	Specialty	33%	N/A	P
GENOTROPIN MINIQUICK 1.2MG	4	Specialty	33%	N/A	P
GENOTROPIN MINIQUICK 1.4MG	4	Specialty	33%	N/A	P
GENOTROPIN MINIQUICK 1.6MG	4	Specialty	33%	N/A	P
GENOTROPIN MINIQUICK 1.8MG	4	Specialty	33%	N/A	P
GENOTROPIN MINIQUICK 1MG	4	Specialty	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GENOTROPIN MINIQUICK 2MG	4	Specialty	33%	N/A	P
GENOTROPIN POWDER FOR INJECTION 13.8MG 5 X 13.8MG CTG	4	Specialty	33%	N/A	P
GENTAK 3MG/GM EYE OINTMENT	1	Generic	$5.00	$12.50	None
GENTAK 3MG/ML EYE DROPS	1	Generic	$5.00	$12.50	None
GENTAMICIN 100MG/NS 100ML	1	Generic	$5.00	$12.50	None
GENTAMICIN 10MG/ML VIAL	1	Generic	$5.00	$12.50	None
GENTAMICIN 60MG/NS 50ML PB	1	Generic	$5.00	$12.50	None
GENTAMICIN 60MG/NS 50ML PB	1	Generic	$5.00	$12.50	None
GENTAMICIN 70MG/NS 50ML PB	1	Generic	$5.00	$12.50	None
GENTAMICIN 80MG/NS 100ML PB	1	Generic	$5.00	$12.50	None
GENTAMICIN 80MG/NS 100ML PB	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GENTAMICIN 80MG/NS 50ML PB	1	Generic	$5.00	$12.50	None
GENTAMICIN 80MG/NS 50ML PB	1	Generic	$5.00	$12.50	None
GENTAMICIN 90MG/NS 100ML PB	1	Generic	$5.00	$12.50	None
GENTAMICIN INJECTION PEDIATRIC 20MG 25 X 2ML VIALSD	1	Generic	$5.00	$12.50	None
GENTAMICIN INJECTION USP 40MG 25 X 20ML VIALMD	1	Generic	$5.00	$12.50	None
GENTAMICIN SULFATE 0.3% OINTMENT	1	Generic	$5.00	$12.50	None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE	1	Generic	$5.00	$12.50	None
GENTAMICIN SULFATE IN NACL SOLUTION FOR INJECTION	1	Generic	$5.00	$12.50	None
GENTAMICIN SULFATE IN NACL SOLUTION FOR INJECTION 1 MG/ML	1	Generic	$5.00	$12.50	None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE	1	Generic	$5.00	$12.50	None
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GENTASOL 3MG/ML EYE DROPS	1	Generic	$5.00	$12.50	None
GEODON 20MG CAPSULE	2	Preferred Brand	$32.00	$80.00	None
GEODON 20MG VIAL	2	Preferred Brand	$32.00	$80.00	None
GEODON 40MG CAPSULE	2	Preferred Brand	$32.00	$80.00	None
GEODON 60MG CAPSULE	2	Preferred Brand	$32.00	$80.00	None
GEODON 80MG CAPSULE	2	Preferred Brand	$32.00	$80.00	None
GLEEVEC 100MG TABLET (90 CT)	4	Specialty	33%	N/A	P
GLEEVEC 400MG TABLET	4	Specialty	33%	N/A	P
GLIMEPIRIDE 1MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLIMEPIRIDE 2MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLIMEPIRIDE 4MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLIPIZIDE 10MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLIPIZIDE 5MG TABLET	1	Generic	$5.00	$12.50	None
GLIPIZIDE AND METFORMIN HCL 2.5-250MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLIPIZIDE AND METFORMIN HCL 5-500MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLIPIZIDE ER 10MG TABLET SR OSMOTIC PUSH 24HR	1	Generic	$5.00	$12.50	None
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR	1	Generic	$5.00	$12.50	None
GLIPIZIDE ER 5MG TABLET SR OSMOTIC PUSH 24HR	1	Generic	$5.00	$12.50	None
GLIPIZIDE XL 10MG TABLET SR OSMOTIC PUSH 24HR	1	Generic	$5.00	$12.50	None
GLIPIZIDE XL 2.5MG TABLET SR OSMOTIC PUSH 24HR	1	Generic	$5.00	$12.50	None
GLIPIZIDE XL 5MG TABLET SR OSMOTIC PUSH 24HR	1	Generic	$5.00	$12.50	None
GLIPIZIDE-METFORMIN 2.5-500MG TABLET	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLUCAGEN 1MG HYPOKIT	3	Non-Preferred Brand	$80.00	$200.00	None
GLUCAGON 1MG EMERGENCY KIT	3	Non-Preferred Brand	$80.00	$200.00	None
GLYBURIDE 2.5MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLYBURIDE 5MG TABLET	1	Generic	$5.00	$12.50	None
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLYBURIDE MICRO 3MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GLYBURIDE TABLET 1.25MG (50 CT)	1	Generic	$5.00	$12.50	None
GLYBURIDE TABLET MICRONIZED 6MG (500 CT)	1	Generic	$5.00	$12.50	None
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET	1	Generic	$5.00	$12.50	None
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLYCOPYRROLATE 0.2MG/ML VL	1	Generic	$5.00	$12.50	None
GLYCOPYRROLATE TABLET 1MG (100 CT)	1	Generic	$5.00	$12.50	None
GLYCOPYRROLATE TABLET 2MG (100 CT)	1	Generic	$5.00	$12.50	None
GLYCRON 1.5MG TABLET	1	Generic	$5.00	$12.50	None
GLYCRON 3MG TABLET	1	Generic	$5.00	$12.50	None
GLYCRON 4.5MG TABLET	1	Generic	$5.00	$12.50	None
GLYCRON 6MG TABLET	1	Generic	$5.00	$12.50	None
GLYSET 100MG TABLET	2	Preferred Brand	$32.00	$80.00	None
GLYSET 25MG TABLET	2	Preferred Brand	$32.00	$80.00	None
GLYSET 50MG TABLET	2	Preferred Brand	$32.00	$80.00	None
GOLYTELY PACKET 227.1 GM/2.82 GM	3	Non-Preferred Brand	$80.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM	3	Non-Preferred Brand	$80.00	$200.00	None
GRANISETRON HCL 0.1MG/ML VIAL INJECTION SOLUTION	1	Generic	$5.00	$12.50	Q:140 /30Days
GRANISETRON HCL 1MG TABLET (20 CT)	1	Generic	$5.00	$12.50	P Q:31 /31Days
GRANISETRON HCL 1MG/ML VIAL	1	Generic	$5.00	$12.50	Q:14 /30Days
GRANISOL 1MG/5ML SOLUTION ORAL	1	Generic	$5.00	$12.50	P Q:310 /31Days
GRIFULVIN V 500MG TABLET	2	Preferred Brand	$32.00	$80.00	None
GRIS-PEG 125MG TABLET	2	Preferred Brand	$32.00	$80.00	None
GRIS-PEG 250MG TABLET	2	Preferred Brand	$32.00	$80.00	None
GRISEOFULVIN 125MG/5ML SUSPENSION ORAL	1	Generic	$5.00	$12.50	None
GUANABENZ ACETATE 4MG TABLET	1	Generic	$5.00	$12.50	None
GUANABENZ ACETATE 8MG TABLET	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GUANFACINE 1MG TABLET	1	Generic	$5.00	$12.50	None
GUANFACINE 2MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
GUANIDINE HCL 125MG TABLET	1	Generic	$5.00	$12.50	None
GYNAZOLE-1 CRE 2%	2	Preferred Brand	$32.00	$80.00	None
GYNODIOL 1.5MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D UPMC for Life Prescription Drug Plan Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.